模擬Tw-DRGs實施對醫院資源耗用之影響-以Cardiac Cath、PTCA及CABG為例

Simulation of the impact of Tw-DRGs implementation to the hospital resource utilization- A Study of Cardiac Cath, PTCA and CABG

黃凱潔(Kai-Chieh Huang)

指導教授 ： 溫信財

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2011年)

https://doi.org/10.6831/TMU.2011.00100

摘要

全民健康保險自開辦以來，醫療費用呈現大幅成長，中央健保局參考先進國家經驗，採用更具效率誘因的Tw-DRGs支付制度，以控制醫療費用成本並提升醫療品質及效率，自2010年起分階段於住院部門逐步推動。從健保提供之醫療服務量來看，就診率以循環系統疾病佔2.4%為最高，其費用支出也非常可觀，而國人十大死因冠狀動脈疾病居第二，因此本研究將以心導管、經皮冠狀動脈氣球擴張及冠狀動脈繞道手術（Cardiac Cath.、PTCA及CABG）之DRG為對象，模擬Tw-DRGs實施對醫院資源耗用之可能影響。
本研究以國家衛生研究院2007-2009年「醫事機構基本資料檔」(HOSB)與「住院費用清單明細檔」(DD)進行串檔後，加上醫事機構診療科別名細檔(DETA)，利用健保局提供之DRG編審系統3.3版，轉出第一階段導入之155項DRGs代碼，挑選出與冠狀動脈疾病相關之DRG共12項計101,346例，探討疾病特性、醫院特性及病患特性對於住院天數、醫療費用及DRG支付額度與實際醫療費用之差額所造成之影響。
研究結果發現，愈接近實施Tw-DRGs之定額給付年度，Cardiac Cath.、PTCA及CABG之住院天數及醫療費用，大多數呈下降趨勢，顯示醫院已採取相關措施以因應不同支付制度帶來之衝擊。由醫療費用之複迴歸分析可知，心導管費用之模式解釋力為0.61(R2=0.61)，疾病嚴重度、醫院權屬別、醫院地區別及住院天數，具有顯著預測能力(p<0.001)。PTCA費用模式解釋力為0.51(R2=0.51)，性別、醫院權屬別、醫院地區別、年度別及住院天數，具有顯著預測能力(p<0.001)。CABG之費用模式解釋力為0.24(R2=0.24)，疾病嚴重度、醫院層級別及住院天數部分，具有顯著預測能力(p<0.001)；而住院天數及費用差額之複迴歸分析亦有類似的結果。由此可知本研究採用之變項在資源耗用上，心臟內科執行之Cardiac Cath及PTCA較心臟外科之CABG手術，有較高的解釋能力。進一步從階層回歸分析亦發現，住院天數對於Cardiac Cath與PTCA之醫療費用與醫療費用差額，是非常重要的影響因素，判定係數r2改變值都在0.35以上。
Tw-DRGs支付制度之實施，各層級醫院的確採取相關措施以因應定額給付之衝擊，而疾病嚴重度、醫院層級別及住院天數均為影響醫療費用的重要因素。故本研究建議醫院必須改善病患之治療及住院流程，且加強醫師病歷書寫的完整性及時效性，疾病分類人員在編碼時應積極主動提出編碼意見及找出有效合併症與併發症，以獲得最適之健保給付。

關鍵字

台灣版疾病診斷關聯群(Tw-DRGs) ； 資源耗用 ； 心導管檢查 ； 冠狀動脈氣球擴張 ； 冠狀動脈繞道手術

並列摘要

Background:
Health care expenditure of National Health Insurance (NHI) in Taiwan has grown significantly since its implementation in 1995. The Bureau of NHI (BNHI) adapted experience from foreign countries and phase in Tw-DRGs in 2010 which used a more efficient incentive payment for controlling the growth of medical costs, improve efficiency and quality of care, According to the statistics of BNHI, circulatory system disease consumed 2.4% services which occupied the highest volume and expenditure of NHI, also it ranked top 2 of Taiwan mortality rate. The purposes of this study are to explore the factors which affected hospital resources utilization of Cardiac catheter, percutaneous transluminal coronary angioplasty and coronary artery bypass graft by Tw-DRGs simulation.
Methods:
We used the 2007-2009 National Health Research Institute inpatient data, which were connected the basic file (HOSB) with expenses file (DD) of hospital, 12 DRGs of circulatory system disease which comprised 101,346 patients extracted by BNHI software (version3.3). The hospital length of stay (LOS), cost and difference between Tw-DRG fix payment and actual expenditure were tested by affecting factors such as hospital characteristics, patient demographic data and disease severity. Then we presented the descriptive and inferential statistics by SPSS16.0 software.
Result:
The results showed the majority of hospital days and costs of Cardiac Cath., PTCA and CABG were decreasing when it closed to the date of Tw-DRGs implementation. We believe that hospital has taken certain measures to cope with the new payment systems. In the multiple regression analysis, the variation of the cost of cardiac catheterization was explained 61% (R2=0.61) by independent variables of severity of illness, hospital ownership, hospital area and LOS (p<0.001). The variation of PTCA cost was explained 51% (R2=0.51) by independent variables of gender, hospital ownership, hospital area, hospitalization year and length of stay are (p<0.001). The variation of CABG cost was explained 24% (R2=0.24) by independent variables of severity of illness, level of hospital and LOS (p<0.001). The variation of LOS and Tw-DRG fix payment and actual expenditure cost difference had similar results in multiple regression analysis. We also found independent variables of Cardiac Cath. and PTCA had higher explanatory power than CABG. Furthermore, the hierarchical regression analysis showed the LOS was the most important factor affecting the hospital costs and Tw-DRG fix payment and actual expenditure cost differences, the coefficients of determination (R2) for the Cardiac Cath and PTCA were all above 0.35.
Conclusion:
The results showed that characteristics of hospital and patient, disease severity were significant factors affected hospital. We suggests that the BNHI should consider above significant factors when revise the payment unit. Besides, workflow of hospitalization and the ability of physician chart documentation should be strengthen, and coder should be more proactive in identifying effective complications and commobidities to optimize the payment.

並列關鍵字

Tw-DRGs, Resource utilization ； Cardiac CATH ； PTCA ； CABG

參考文獻

黃雅姿(2010)。實施TW-DRGS前影響醫院住院資源利用之因素及年度變化－以婦產科為例。 未出版之碩士論文，臺北醫學大學，台北市。

曾鴻如(2008)。台灣地區1999~2003年經皮冠狀動脈擴張術之醫師服務量與醫療利用及品質之相關性分析。科技教育課程改革與發展學術研討會論文集(2008)，67-73。

張苙雲(2007)。DRGs政策實施之預期影響－民間團體觀點。醫療品質雜誌，1(5)，54-57。

錢慶文、邱瓊慧(1999)。醫院因應外在環境變化之能力研究：以闌尾切除術實施論病例計酬制度為例。中華公共衛生雜誌，18(6)，432-444。

莊逸洲、陳理(1994)。前瞻性付費制度(Prospective Payment System)之醫療管理模式研究。中華公共衛生雜誌，13(6)，485-499。